There is evidence to suggest that 3% of deaths that occur in healthcare settings could be classed as avoidable (Hogan et al, BMJ Open, 2015). The purpose of the NQB guidance is to support trusts to learn from deaths and identify themes for improvements in care systems through structured case record reviews and, where appropriate, investigations.

The recurrence of problems can be prevented by identifying themes and generating quality improvements for care systems.

The first quarterly regional mortality review group meeting bringing together clinical and managerial staff from ten organisations across the healthcare sector took place in December 2017. This programme aims to improve the standardisation of mortality review processes within community, mental health and secondary care settings and to support the development of quality improvement projects based on the thematic learning from mortality reviews.

Training has already been provided to 25 staff on the Royal College of Physicians’ Structured judgement review tool with training planned for a further 30 in April 2018.

The group is also learning from West of England AHSN who were early implementers in structured mortality reviews.